COPD winter approach

There has been increased interest recently on focusing on those at greatest risk of admission from their COPD, and providing extra support to them including remote monitoring. I’ve been working with teams in Bristol on this model, and there are also great services in Airedale, Frimley and Cheshire and Merseyside. But despite achieving stunning results in terms of reduction of admissions, these remain the exception rather than the rule.?

So it is really terrific to see the recent announcement of a Winter Fund designed to support the scale of this model across the NHS in England. ICBs can bid for ￡125k for a tech enabled service, to be established rapidly to support patients ahead of and during winter 24/25. Now while this may not cover all of the costs, it is a very valuable contribution towards them and shows just the right direction of travel from the centre.?

This could lead to a host of areas setting up services to support their most vulnerable this winter, and the NHS reaching thousands of patients in this new model.?What is also exciting is that the aim is to test models this winter before planning an at scale approach for England, based on impact and learning. The letter issued on 26 July is titled:

COPD Winter Approach: 2024/25 Call for Applications for Targeted Funding

The introduction reads as follows - “The Cardiovascular Disease and Respiratory Programme (CVD-R) and the Primary Care and Community Services (PCCS) Delivery Unit are leading on the development of an approach for chronic respiratory disease management, to enable and support ICBs to prepare for winter and beyond. This includes practical and proactive approaches to identify and support people with COPD most at risk of exacerbation in winter, and provision of strengthened support to those exacerbating.

NHS England is inviting applications for Target Funding from sites in a position to implement and test this approach this winter. This will support national learning and understanding of implementation models, barriers and enablers to delivery and potential impact as we consider how this can be delivered on a larger scale in future years.”

All ICSs already have tech that they are using for their virtual wards that can be extended to this new application. The guidance recommends also using a digital support technology tool that has been supported by a NICE early value assessment or EVA. The bid process closes on 19th August 2024 so there’s no time to lose.?

I’d definitely recommend going for it and here are my top tips based on my experience to date.?

1. Start now

I would get the kernel of the case designed this week and start at the same time on running the data to work out your cohort. Begin working out how many patients you want to reach - 300-500 should make a real difference - and what the costs of this will be, so that if there needs to be a contribution from other sources (UEC or winter funding, Health Inequalities funding or other funds that the ICS and partners can identify) the process for unlocking this can be begun in parallel.?Bring together the key leads to form a tight group to get the service designed and bid together at pace.

It will depend on what services exist locally and how much, if any, spare capacity these have. But my rule of thumb would be that with the ICB match funding the ￡125k, a total budget of ￡250k an ICB could run a good service for around 5 months for around 300 patients with severe COPD, across the peak admission period if Nov - March. More budget would mean more people could benefit, so for c500 patients it would be ￡400k, or ￡275k from the ICB with the ￡125k from NHSE.?

2. Work out how you want to run it

If you already have

• mature respiratory Virtual Ward provision and a large ICB wide hub?
• a strong Integrated Respiratory Team ideally with some capacity?

You will be able to progress most rapidly.?

The existing large scale models - such as Airedale which now looks after over 4,000 people with COPD remotely, and Bristol’s Living Well with COPD model which includes Health Coaching - recruit their patients to the COPD remote monitoring support programme via the Acute Trusts. This uses a text messaging provider that patients are familiar with, in both of these cases it’s DrDoctor, increasing confidence in the messaging. It also means it’s straightforward to recruit at scale, in contrast to doing through the patients’ GP practice where processes including setting up multiple data sharing agreements can introduce delay.?

It’s valuable to also have some time from a member of Trust admin staff who can make the follow-up calls. This seems to have played a key role in ensuring that the cohort includes those who are most deprived.?

The review of remote monitoring results can be undertaken by the existing hub team, likely with additional staff recruited or this service can be outsourced to a partner, which is the Bristol model.?

3. Identify the actual patient cohort?

I’d recommend identifying a cohort that’s 3 times the size you want to recruit. While there are whizzy ways to do this including using AI etc cohort identification really doesn’t need to be lengthy or complicated. In the two Bristol acutes the information teams simply ran a search of people with a diagnosis of COPD and frequency of hospital admissions.?

The Clinical lead for the service, a Respiratory Consultant, reviewed the list for any cases that wouldn’t be suitable. We then started contacting patients working our way down the list in order of historic admissions. In Frimley they use the Johns Hopkins scoring to identify those at greatest risk.?

4. Begin contacting patients & optimising soonest?

The guidance is very clear on OPTIMISE and with lots of patients to impact before winter it is ideal to begin contacting the first patients in August & September - potentially before hearing if the bid is successful - and kicking off the optimisation process.?

5. Line up partners?

It’s important that this new service fits in seamlessly with existing provision and works as a collaboration. Health Innovation Networks have been incredibly useful in mobilising and evaluating these sorts of service in the past, so valuable to include. Set up an agile project structure to support delivery with individual partners having autonomy to progress at pace. Think about Comms across the organisation and the types of support already available that the service can direct people to.?

There are great resources provided by Asthma+Lung for people with COPD such as their on line singing group every Monday.

https://www.asthmaandlung.org.uk/groups-support

It’s likely that the service will find people who are isolated and lonely. Here services such as social prescribing to link to local activities that can reduce isolation and increase activity can be useful. Or to get support from NHS Volunteers or the AgeUK befriending service.

https://nhscarevolunteerresponders.org/

Others may need help with fuel costs or benefit advice and need linking up with local provision. There are also some amazing local charities such as the Community Freezer that has been established precisely to help vulnerable groups such as these. A proportion will still be smoking and need support and nicotine replacement therapy to quit for good.?

https://www.ageuk.org.uk/services/befriending-services/

What kind of impact can we expect to see??

The sites doing this at scale are seeing Emergency Admissions reduce by 40-60% in the cohort supported by Remote Monitoring for their COPD. They are seeing similar reductions in Acute Bed Days used and Emergency Attendances as well as evidence of reductions in GP visits and Outpatient appointments.?

It’s an exciting moment, and great to see the National? Clinical Respiratory team behind this important support. There are few things that we can do across the NHS to improve our likelihood of a better winter but this is one of them. And the great news is that people living with COPD tell us that they love this model?

https://www.nice.org.uk/guidance/gid-hte10030/documents/draft-guidance